This is a blog by a former CEO of a large Boston hospital to share thoughts about hospitals, medicine, and health care issues.

Saturday, January 19, 2008

What's in a PCAC?

Following on our theme below, I am presenting a bit more on our governance of hospital safety and quality to provide background to others in the field who might be interested. A friend asked me how our Patient Care Assessment and Quality Committee (PCAC) is constituted and what its charter is. Here it is in its entirety. The key points are that its job is related to the overall institutional goals established by the Board of Directors (the ones mentioned below), as well as statutory responsibilities. Also, that membership by the lay leadership (entitled "Medical Center Governance" below) always exceeds that of internal management and clinical leadership. Note, too, the inclusion of the Vice President of Education to ensure that quality and safety programs are integrated into the educational programs for both medical students and residents -- very important in an academic medical center.

This is a hard-working committee for the volunteer leadership, meeting monthly and dealing with difficult and challenging issues. We have great appreciation for those people, who devote hours well beyond the committee meetings in staying informed and thinking about the most important topics on the Board's agenda.

Mission:The mission of the Patient Care Assessment and Quality Committee (PCAC) is to support the aspirations for clinical quality and safety for BIDMC as set forth by the Board of Directors, and make appropriate recommendations for improvement. The PCAC shall also serve the role of Medical Peer Review Committee as defined under the statutes of the Commonwealth of Massachusetts.

Charge and Scope:Monitor the occurrence of harm to BIDMC patients, with a focus on response and corrective action when harm occurs.Select and monitor priority metrics that evaluate clinical quality and safety processes and outcomes achieved within BIDMC.Recommend to the Board of Directors, at least annually, priority initiatives for improving quality and safety of care at BIDMC, and monitor the extent to which approved priority initiatives are satisfactorily executed.Ensure that BIDMC remains alert to current best practices for quality and safety, at BIDMC and other entities (in health care as well as other settings), and recommends appropriate adoption. This shall include ensuring that best practices within BIDMC itself are spread and implemented throughout the organization.Approve annually the Qualified Patient Care Assessment Program.Ensure that all regulatory reporting mandates for clinical performance, including the filing of major incident reports to the Commonwealth, are met.Ensure that members of the Committee have the appropriate knowledge and training necessary to carry out the mission of the committee.

Committee Chair:Member of BIDMC Governance, Appointed by Chair of Board of Directors

6 comments:

I am just astounded at the apparently superhuman range of activities handled by some people. Like, although I feel like my life is already full, so it's frustrating I also feel called to participate in supporting these activities; yet the lives of the people on this committee must surely have more and broader accountabilities than mine. Like your guy Halamka - "Chief Information Officer of the CareGroup Health System, Chief Information Officer and Dean for Technology at Harvard Medical School, Chairman of the New England Health Electronic Data Interchange Network (NEHEN), CEO of MA-SHARE (the Regional Health Information Organization), Chair of the US Healthcare Information Technology Standards Panel (HITSP)," AND, in his spare time, a practicing Emergency Physician.

I've always heard "If you want something to get done, ask a busy person," apparently because they have some knack. Whatever it is, I'd like to learn it.

Paul, this is very interesting; it resembles the "Performance Improvement Council" we had at our hospitals except for the addition of a large # of laymen and a somewhat broader charter. I have a couple questions:a. There appears to be no representative from nursing on the committee,or am I missing that hidden within the titles of the listed executives?b. What's the difference between BIDMC Governance and Medical Center Governance? Are these both separate committees, or what?c. I am quite curious about the medical peer review function. Perhaps this is mandated by your state. Does this mean recredentialing, or does the committee deal with actual disciplinary actions of physicians on your staff? Or perhaps it would be easier if you would just define "peer review' as used at BIDMC.

Thanks for an illuminating post. I can see adding laymen (I assume members of the community/patients) would prevent the "group think" that often prevails inside hospital walls.

Medical Executive Committee = formal body of MDs on the faculty who promulgate the rules and rgeulations of service in the hospital, including medical peer review, credentialing, disciplinary actions, and the like. THE MEC reports on its activities to the BIDMC Board of Directors and also to the PCAC.

Nursing does not have a position on PCAC, but the SVP for Clinical Operations, who oversers nursing, staffs the committee.

It does clarify; thanks. I hope the PCAC exercises its oversight over the MEC on those disciplinary actions. As a onetime MEC member, I felt that many times the majority gave erring docs a pass on things they should have called them on. Maybe it's never that specific by the time it gets to PCAC. And there are always confidentiality issues.But in summary, I like the lay Board members serving on your quality assurance body. Good idea!

Formal evaluation of the CEO is carried out by the entire Board. The various Board committees, including PCAC, Finance, and so on report to the Board on the CEO's performance in their araes of jurisdiction.